Cartwright Alice F, Angeles Gustavo, Su Jessica, Wallace Maeve, Curtis Siân, Speizer Ilene S
Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
Womens Health Issues. 2025 Aug 14. doi: 10.1016/j.whi.2025.07.002.
Medicaid expansion has the potential to increase access to contraception and improve women's health, although existing research examining state-level variation provides mixed evidence. The neighborhood context plays a crucial role in understanding the effects of Medicaid expansion on contraceptive use, as structural inequalities within neighborhoods may shape access to health care and reproductive services.
We used a unique restricted dataset of 13,224 female respondents ages 15-44 years interviewed in the 2011-2019 waves of the National Survey of Family Growth (NSFG). We merged these data with indicators of state Medicaid expansion status and respondents' neighborhood context, operationalized as Index of Concentration at the Extremes (ICE) scores. We used quasi-experimental difference-in-differences models to assess if Medicaid expansion impacted provider-dependent contraceptive use and method type differentially by neighborhood-level context. We used multivariable linear probability and multinomial logistic regression models adjusting for individual and community covariates and state/region fixed effects.
Living in a Medicaid expansion state was associated with significant increases in provider-dependent contraceptive method use among respondents in the most deprived neighborhoods (17.9 percentage points, 95% CI [9.0, 26.9], by 2017-2019). Specifically, long-acting reversible contraception (LARC) use increased 7.6 percentage points (95% CI [0.6-14.7]) and use of no method or barrier/coital methods declined 17.5 percentage points (95% CI [-26.3, -8.7]) among those in the most deprived neighborhoods by 2017-2019.
Changes in state-level policies can have major impacts on health systems, but the example of Medicaid expansion underscores the differential impacts on people with less access to health resources, such as those living in structurally disadvantaged neighborhoods. Ultimately, further expansion of Medicaid could facilitate access to the full range of contraceptive methods and advance population health equity in additional U.S. states.
医疗补助计划的扩大有可能增加避孕措施的可及性并改善女性健康，尽管现有针对州层面差异的研究提供了不一致的证据。社区环境在理解医疗补助计划扩大对避孕措施使用的影响方面起着关键作用，因为社区内的结构性不平等可能会影响获得医疗保健和生殖服务的机会。
我们使用了一个独特的受限数据集，该数据集来自于2011 - 2019年全国生育健康调查（NSFG）中接受访谈的13224名年龄在15 - 44岁之间的女性受访者。我们将这些数据与州医疗补助计划扩大状况指标以及受访者的社区环境指标（以极端集中度指数（ICE）得分来衡量）进行了合并。我们使用准实验性的差异分析模型来评估医疗补助计划的扩大是否会因社区层面的环境而对依赖医疗服务提供者的避孕措施使用和方法类型产生不同影响。我们使用多变量线性概率模型和多项逻辑回归模型，并对个体和社区协变量以及州/地区固定效应进行了调整。
到2017 - 2019年，生活在医疗补助计划扩大的州与最贫困社区的受访者中依赖医疗服务提供者的避孕方法使用显著增加有关（增加了17.9个百分点，95%置信区间[9.0, 26.9]）。具体而言，到2017 - 2019年，最贫困社区中长效可逆避孕法（LARC）的使用增加了7.6个百分点（95%置信区间[0.6 - 14.7]），而未采取任何避孕措施或使用屏障/性交中断法的比例下降了17.5个百分点（95%置信区间[-26.3, -8.7]）。
州层面政策的变化可能对卫生系统产生重大影响，但医疗补助计划扩大的例子凸显了对那些获得卫生资源较少的人群（如生活在结构上处于劣势社区的人群）的不同影响。最终，进一步扩大医疗补助计划可能会促进获得全面的避孕方法，并在美国其他州推进人口健康公平。
